198603286-6-10-2021-28-AS-MVAO-CDMQA6-20220419115926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 06/10/2021
Date Signed: 06/10/2021 01:56:22 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2021 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210602114240

FACILITY NAME:	PASADENA VILLA SENIOR LIVING		FACILITY NUMBER:	198603286
ADMINISTRATOR:	MURPHY, MICHAEL		FACILITY TYPE:	740
ADDRESS:	1811 N. RAYMOND AVE		TELEPHONE:	(626) 791-6232
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	97	CENSUS: 38	DATE:	06/10/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Assistant Administrator/Alexander Solorio and Executive Director/ Kandice Vergara Williams		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility does not have an appropriate evacuation plan in place.

Resident's were not properly evacuated.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Jose Villalobos conducted an unnanounced complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Alexander Solorio and Executive Director Kandice Vergara Williams. The purpose of the visit was discussed.

The investigation consisted of the following: LPA's requested and received copies of facility staff roster, resident roster, emergency disaster plan, plan of operation and facility sketch. Incident Report dated 5/27/21 was reviewed. LPA toured the physical plant and food supply was observed. LPA interviewed Staff #1-5 (S1-S5), and residents #1-4 (R1-R4).

The investigation revealed the following: In regards to "Facility does not have an appropriate evacuation plan in place" it was alleged that the evacuation plan established by the facility was not appropriate for the number and type of resident's residing at the location...

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210602114240

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 06/10/2021

NARRATIVE

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(5) of (5) staff interviewed deny the allegation. (4) of (4) residents interviewed could not corroborate the allegations. File review shows that the facility is a Residential Care facility for the Elderly licensed for a capacity of 97 Non-ambulatory, of which 30 may be bedridden. The current census at the time of this visit is (38) of which (8) are bedridden. Documents reviewed show that the facility has an emergency disaster plan in place with an evacuation plan for all residents. This plan was used on the date of 5/27/21 when there was a fire in room #19 of the facility. Based on LPA's observations and interviews there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

In Regards to the allegation "Resident's were not properly evacuated", it was alleged that the bariatric beds used by some resident would not pass through the doors. Residents were evacuated to directly in front of the building. (5) of (5) staff interviewed deny the allegation. (4) of (4) residents interviewed could not corroborate the allegation. LPA toured the facility and observed that there are (49) total rooms for residents and all (49) bedrooms have a fire clearance for non-ambulatory. These rooms have large doors capable of fitting bedridden residents as well as exit doors leading to outdoor court yards or facility exits that are also large enough to fit bedridden residents. Interviews show that on 5/27/21 all 36 residents at that time were evacuated from the facility. (3) of (4) residents interviewed are bedridden and (2) of (4) were able to state that staff was able to evacuate them out of the facility. Interviews with (5) of (5) staff state that the bedridden residents were moved out of the facility using the front door exits in front of the facility and staff were manually opening the parking gates to move them to the parking lot, which is the designated assembly point. Based on LPA's observations and interviews there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator Alexander Solorio and Executive Director Kandice Vergara Williams

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

LIC9099 (FAS) - (06/04)

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